Complainant Mahesh Prasad filed this complaint with Rs. 1,19,460/- with 12% Interest and compensation of Rs. 50,000/- for mental harassment and litigation cost of Rs. 30,000/-.
2 The case of the complainant is that complainant is the retired officer of the SAIL and taken Mediclaim Policy having policy No. 4721777. Complainant due to eye problem went to Shroff Eye Clinic, New Delhi on 13.06.2015 and he undergone MICS with infra ocular lens implantation in both the eyes on 17.06.2015 and 22.06.2015 and discharged on the same day respectively. The O.P. No.1 E-Meditek has not settled the claim and after 6 months a legal notice was sent on 06.02.2016 to the O.Ps. but no reply has been received. The complainant got the discharge paper and signature of the doctors and sent to E-Meditek on 09.03.2016 when it was reported by O.P. No.1 but even though the claim was not settled. Hence this case has been filed.
3 The Following documents has been filed-
Anx-1 And1/1 Copy of Discharge Certificate.
Anx-2 to2/3Copies of acknowledgment slip of the claim and Claim
Form.
Anx-3 Copy of legal notice.
Anx-4 Copy of reminder letter regarding documents by O.P. No.1.
An x-5 to 5/13 Copies of Medical Bill Receipts.
Anx-6 to 6/1 Copies of follow up medical advice after operation.
Complainant also examined himself on affidavit as witness No. 1.
4 O.P. No.1 &2 E-Meditek did not appear and Ex-parte proceeding has been initiated.
5 O.P. No.3 G.M. final settlement department SAIL appeared and filed W.S. It is submitted that this O.P. has no relationship of consumer between the complainant. This O.P. only collects premium toward, Group Accident Insurance Policy from the member and forwards to the insurance co. Therefore, this O.P. has not committed any deficiency in service and the claim of the complainant was forwarded to TPA E-Mediate hired by insurance co. to process the claim and therefore, this complaint is not maintainable against this O.P.
6 O.P. No.4 M/s United India Insurance Co. Ltd. appeared and filed W.S. and it is submitted that No Policy bearing No. 4721777 was issued to the complainant and further it is submitted that the complainant has not informed within 24 hours regarding the operation and submit the claim after 6 months from the date of operation. It is also submitted that after several letter issued on 23.07.2015, 08.08,.2015,19,10,.2015,04.11.2015 and finally 20.11.2015, the complainant never fulfilled the requirement of documents. On 09.03.2016 complainant furnished incomplete document which was not sufficient for claim process and delay was not explained. It was not accepted. It is submitted that the complainant has suppressed and procedured various distorted facts for filing this complaint and it is submitted that the repudiation of claim by E-Meditek which is justified, and therefore, this complaint is liable to be dismissed.
F I N D I N G S
7 We perused the record and hold that complainant is a consumer since paied premium for the Mediclaim policy between SAIL and Insurance Co. and he is a beneficiary under the scheme. Therefore, complainant is a consumer and the dispute is a consumer dispute.
8 It has been argued on behalf of the complainant that the policy bearing No. 41100/48/15/410000002 has been admitted by insurance co. in its written statement. It is also submitted that No. 4721777 is the MIN Number (Member Identification Number). It is submitted on behalf of the insurance co. that no information given within 24 hours regarding operation which is violation of terms and conditions and the claim was submitted after 6 months. Therefore, the complainant is not entitled for the claim and has been rightly repudiated and there is no deficiency on the part of the insurance Co.
On perusal of record that complainant has wrongly stated the policy number which mentioned in the W.S. of the O.P. O.P. has not denied that no policy has been issued to cover up the claim of the complainant meaning thereby the policy is admitted. As regard the objection of the O.P. that no information was given within 24 hours against the terms and conditions, no document has been filed by the complainant when the information was given to the SAIL or Insurance Co. From Anx-2 series, it appears that the claim form dated 21.07.2015 filed by the complainant was submitted to O.P. No.1 E-Meditek on 09.03.2016 whereas the date of the operation was 17.06.2015 and 22.06.2015 as per Anx-1 series which are discharge summary. Although the claim form has been signed on 21.07.2015 but deposited before O.P. No.1 E-Meditek who is third party administrator employed by insurance Co. for assessing the claim on 09.03.2016. No terms and condition has been filed by the O.P. to assess the delay in filing of the claim form. But for such a technical ground of delay unless the bill submitted by the claimant found to be wrong, the entire claim of the complainant cannot be denied. And therefore, we found the O.P. insurance co. is deficient in service for not allowing the claim.
9 It is fact that the claim form was submitted after some delay for which 10% of claim amount should be reduced on the basis of natural justice and as such the complainant is entitled for Rs. 1,19,460 – Rs. 11,946(10% less) = Rs. 1,07,514/- (Rs. One lac seven thousand five hundred fourteen) only in round figure Rs. 1,07,520/- and O.P. Insurance co. is liable to pay this amount to the complainant.
10 Accordingly we allow the part claim of Rs. 1,07,520/- in favour of complainant and O.P. United India Insurance Co. Ltd. is directed to pay Rs. 1,07,520/- (Rs. One lac seven thousand five hundred twenty) only with interest of 8% (eight) per annum from the receipt of the claim dated 09.03.2016 till realization.
The Insurance Co. is also directed to pay compensation of Rs. 5000/- (Rs. Five thousand) only for mental agony and litigation cost of Rs. 2000/- (Rs. Two thousand) only to the complainant.
All the payments must be paid within 60 days of passing of this order, failing which the rate of interest of the part claim amount shall be enhanced to 10% (ten percent) per annum till realization.
